PFI_12mmX178mm.

pdf + eps format

Journal of Child Psychology and Psychiatry **:* (2021), pp **–** doi:10.1111/jcpp.13480

Annual Research Review: Attention-deficit/

hyperactivity disorder in girls and women:
underrepresentation, longitudinal processes, and key
directions
Stephen P. Hinshaw,1,2 Phuc T. Nguyen,1 Sinclaire M. O’Grady,1 and
1
Emily A. Rosenthal
1
Department of Psychology, University of California, Berkeley, Berkeley, CA, USA; 2Department of Psychiatry and
Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA

Attention-deficit/hyperactivity disorder (ADHD) – and its underlying behavioral dimensions of inattention and
hyperactivity–impulsivity – have been understudied in females. We first cover the conceptual issues of prevalence,
diagnostic practices, diversity, comorbidity, and causal factors, plus forces limiting awareness of ADHD in females.
After a narrative review of cross-sectional and longitudinal findings, we conclude the following. (a) Girls meet
diagnostic criteria for ADHD at just under half the rates of boys, a ratio that becomes much closer to equal by
adulthood. (b) Girls and women with ADHD show a predominance of inattention and associated internalizing
problems; boys and men display greater levels of hyperactive–impulsive symptoms and associated externalizing
problems. (c) Sex differences in ADHD symptoms and related outcomes depend heavily on the clinical versus
nonreferred nature of the samples under investigation. (d) Females with ADHD experience, on average, serious
impairments, with a particularly heightened risk for problems in close relationships and engagement in self-harm. (e)
Clinicians may overlook symptoms and impairments in females because of less overt (but still impairing) symptom
manifestations in girls and women and their frequent adoption of compensatory strategies. Our review of predictors
and mediators of adult outcomes highlights (a) the potential for heterotypically continuous pathways in females with
childhood ADHD and (b) developmental progressions to self-harm, intimate partner violence, unplanned pregnancy,
and comorbid psychopathology. Focusing on ADHD in females is necessary to characterize causal and maintaining
mechanisms with accuracy and to foster responsive interventions, as highlighted in our closing list of clinical
implications and research priorities. Keywords: ADHD; developmental psychopathology; self-harm; girls and
women.

(see Williamson & Johnston, 2015, for an incisive

Introduction
review of gender differences in adult ADHD).
Attention-deficit/hyperactivity disorder (ADHD)
Male-dominated samples have long characterized
involves developmentally extreme and cross-
a great many behavioral science and biomedical
situational manifestations of (a) inattention and/or
endeavors (including animal research; see Beery &
(b) hyperactivity–impulsivity. Considerable research
Zucker, 2011). Three decades ago, calls emerged for
reveals substantial impairments in key domains of
equitable representation of females in science and
functioning throughout the life span for individuals
medicine (see U.S. guidelines [National Institutes of
either surpassing or falling just below diagnostic
Health, 1994], which have received periodic updates;
thresholds (Hinshaw, 2018). Given space limita-
see also updated U.K. guidelines [Great Britain
tions, we direct readers to the masterful review of
Home Office, 2018]). Eating disorders and depres-
developmental origins of ADHD in Nigg, Sibley,
sion, which both display female overrepresentation,
Thapar, and Karalunas (2020) and the provocative
are exceptions to this widespread trend. Yet even
overview of biological correlates of ADHD during
when mixed-sex samples are available, many scien-
adolescent development in Shaw and Sudre (2021).
tists fail to examine sex-related differences or mod-
Until recently, however, almost all research in this
erator effects (for enhancing research on sex
area has focused on boys and men. Female presen-
differences, see Rich-Edwards, Kaiser, Chen, Man-
tations have been largely overlooked in both clinical
son, & Goldstein, 2018; Tannenbaum, Greaves, &
and research settings (Young et al., 2020). To redress
Graham, 2016). Merit also exists in considering
this historical neglect, we provide current evidence
conditions like ADHD in an all-female context (Hin-
on both (a) sex differences with respect to ADHD
shaw, 2018; Owens, Zalecki, & Hinshaw, 2017).
across the life span, and (b) female-specific impair-
Despite growing commitment to diversify research
ments, mechanisms, and developmental pathways
samples, a lack of substantial progress toward full
female representation remains (Hartung & Lefler,
2019; Mazure & Jones, 2015; see also Eagly, Eaton,
Conflict of interest statement: No conflicts declared. Rose, Riger, & McHugh, 2012). A similar critique can

© 2021 Association for Child and Adolescent Mental Health.

2 Stephen P. Hinshaw et al.
be made regarding the lack of research on, for
example, males with eating disorders or depression.
A core objective of gender-representative samples is
generalizability, a point that also pertains to socioe-
conomic and racial diversity. Empirically question-
ing the assumption of universal etiologies,
developmental pathways, and/or therapeutic pro-
cesses across males and females should result in
better understanding of the underlying mechanisms.
Similarly, comprehending sex differences in and
female presentations of ADHD should enhance both
scientific accuracy and clinical prowess.
As discussed below, the prevalence of ADHD in
boys is 2–2.5 times higher than its prevalence in
girls. A male predominance is the case for most if not
all neurodevelopmental disorders (Rutter, Caspi, &
Moffitt, 2003). We therefore open with three concep-
tual issues about sex differences. First, theories exist
regarding the nature of psychopathology with lower
prevalence in either sex (Eme, 1979, 1992; Gualtieri
& Hicks, 1985). According to the ‘gender paradox’
(Loeber & Keenan, 1994), the sex with lower preva-
lence is expected to display more severe features as
well as higher rates of comorbid disorders. Two
explanatory models are relevant. (a) The polygenetic
multiple threshold model holds that the lower-
prevalence sex (e.g., females with ADHD) would need
to have greater levels of family history and a higher
genetic ‘load’ and/or environmental disadvantage to
meet diagnostic criteria (see Taylor et al., 2016). (b)
In the constitutional variability model, boys are
slower to mature than girls, leading to a greater
propensity for exhibiting a wide spectrum of neu-
rodevelopmental symptoms. Given the extreme gen-
der atypicality of her symptoms in relation to other
females, a girl with significant ADHD would thus be
likely to have demonstrable neural dysfunction.
Second, even in representative samples, the sex
ratio of diagnosed ADHD approaches 1.5:1 or lower
during the adult years (Kessler et al., 2006; Nuss-
baum, 2012). For one thing, girls are more likely
than boys to display inattention as the predominant
symptom domain (Biederman et al., 2002), and
inattentive symptoms are more likely to persist
through adulthood (e.g., D€ opfner, Hautmann,
G€ortz-Dorten, Klasen, & Ravens-Sieberer, 2015;
Larsson, Dilshad, Lichtenstein, & Barker, 2011).
Thus, females appear prone to display a more ‘life-
persistent’ form of ADHD. As well, symptom lists for
ADHD are biased toward male behaviors (e.g., phys-
ical overactivity or extreme risk-taking) as opposed
to female-related manifestations (e.g., excessive ver-
balizations or more subtle indicators of impulsivity;
see Quinn & Madhoo, 2014; Young et al., 2020).
Furthermore, females are less likely than males to
display disruptive behaviors (or at least have a later
onset of such), curtailing early detection. Finally,
children are rated for ADHD via parent and teacher
reports, but adult assessment is typically based on
self-report – with women more likely to disclose
relevant problems (e.g., Millenet et al., 2018; Vil-
dalen, Brevik, Haavik, & Lundervold, 2019).
Third, as reviewed by Asherson and Agnew-Blais
(2019), over the last decade several birth-cohort
studies challenged the assumption that ADHD is a
neurodevelopmental disorder inevitably beginning in
childhood. Strikingly, adult-onset individuals in
these investigations comprised half or more women.
Yet (a) many such cases have heightened but sub-
threshold ADHD symptoms in childhood, (b) comor-
bidities explain a substantial proportion of so-called
adult-emergent cases, and (c) far more evidence
exists for adolescent or very-early adult onset of
ADHD than in later adulthood. Regardless, ADHD is
increasingly salient for females by the adult years.
We provide a final note on terminology, as to
whether discussion should focus on gender versus
sex differences (Gentile, 1993). Following conven-
tion, we use sex to denote biological male or female
status (acknowledging that this designation is not a
binary) and gender to depict the social and/or
cultural roles applied to biological sex or the per-
sonal identification with such roles.
ADHD and psychopathology: background
issues
The topic of ADHD is the subject of a voluminous and
still-growing literature. Issues regarding this diag-
nosis are often controversial in both science and the
public eye (Hinshaw, 2018). We contend that a
developmental psychopathology perspective is
essential (Hinshaw, 2017). Rather than viewing
ADHD as a static diagnostic entity, a focus on its
dimensional components is often fruitful (see the
Research Domain Criteria [RDoC]; Cuthbert & Insel,
2013). Furthermore, incorporating concepts such as
transactional models of development, multiple levels
of analysis, heterotypic continuity, and the conflu-
ence of heritable and psychosocial underpinnings of
symptom domains will continue to be illuminating.
Prevalence, including race/ethnicity
Given the lack of validated biomarkers for any
mental health or neurodevelopmental syndrome, it
is impossible to gauge the actual prevalence of
conditions like ADHD. Diagnosed prevalence rates
of ADHD in the United States have been rising
steadily over the past several decades in both boys
and girls (Hinshaw & Scheffler, 2014). According to
population surveys, 9.4% of all children and adoles-
cents aged 2–17 years have received an ADHD
diagnosis, as reported by parents, with a male:
female sex ratio of 2.3:1 (Danielson et al., 2018).
Such estimates are above those of nearly every other
country on earth with relevant data, especially when
rarely diagnosed 2- to 3-year-olds are excluded
(Polanczyk, De Lima, Horta, Biederman, & Rohde,
2007; Polanczyk, Willcutt, Salum, Kieling, & Rohde,
© 2021 Association for Child and Adolescent Mental Health.

2014). We note, however, that regional differences
are evident in the United States and other countries.
One potential explanation has to do with school-
testing policies known as consequential accountabil-
ity statutes (Fulton, Scheffler, & Hinshaw, 2015). An
unintended consequence is that rates of ADHD
diagnosis rise precipitously for a state’s most impov-
erished children when such ‘test scores at all costs’
policies are enacted (Hinshaw & Scheffler, 2014). In
addition, Caye et al. (2020) review the effect of
‘relative age’ – that is, being young for one’s grade
level – on the propensity for ADHD diagnosis. In both
instances, sex differences are unclear.
Regarding adult ADHD, prevalence estimates are
confounded by the developmental reality that phys-
ical activity and behavioral impulsivity decline from
childhood through adulthood (e.g., Larsson et al.,
2011). After the teen years, it becomes difficult to
ascertain when symptom levels are indicative of
remission. Accordingly, estimates of the percentage
of children who maintain the diagnosis into adult-
hood range widely, from under one-third to a sub-
stantial majority (Guelzow, Loya, & Hinshaw, 2017;
Sibley et al., 2021). Still, a growing consensus is that
well over half of diagnosed children display impair-
ing adult symptoms even when strict diagnostic
criteria are no longer met (Biederman et al., 2010;
Uchida, Spencer, Faraone, & Biederman, 2018).
The racial composition of who gets diagnosed with
ADHD has shifted substantially of late, at least in the
United States. Although diagnosis was reserved
largely for White, middle-class boys during the
20th century, C enat et al. (2021) documented that
Black youth have now surpassed White youth in
terms of diagnosed prevalence, in both sexes (see
also Danielson et al., 2018). Furthermore, although
Latinx youth have traditionally had lower diagnostic
rates than other ethnic groups, the gap is closing
(Hinshaw & Scheffler, 2014). Greater awareness
among professionals is relevant, but it is possible
that ADHD may become – or has recently become – a
convenient diagnostic label for youth experiencing
impoverishment and/or trauma (Hinshaw & Schef-
fler, 2014).
Diagnostic practices
Related to this last point, we comment briefly on the
kinds of assessment practices typically used to
diagnose ADHD in clinical as opposed to research
settings. Despite evidence-based guidelines pre-
pared by the American Academy of Child and Ado-
lescent Psychiatry (Pliszka & AACAP Work Group on
Quality Issues, 2007) and the American Academy of
Pediatrics (Wolraich et al., 2019) in the United
States, and the National Institute for Health and
Care Excellence (2019) in the U.K., general pediatri-
cians and adult practitioners are often not suffi-
ciently trained in (or reimbursed for, in the United
States) such evidence-based assessments. A 15-
© 2021 Association for Child and Adolescent Mental Health.
ADHD in girls and women 3
minute office visit without normed informant rating
scales, developmental histories, medical examina-
tions, or testing to consider comorbid psychiatric
and learning conditions may lead to both overdiag-
nosis and underdiagnosis, with the former more
likely for boys but the latter for girls (Hinshaw &
Scheffler, 2014). Major dividends should accrue
from adequate resources for accurate assessments,
including the recognition that ADHD clearly exists in
girls and women. In addition, inattentive symptoms
should be accounted for across the life span, espe-
cially during transitions from elementary to sec-
ondary school, which present new challenges with
less adult scaffolding, and to pregnancy and parent-
hood, including hormonal changes that may exacer-
bate symptoms (Young et al., 2020). Finally, mood
and anxiety symptoms frequently accompany female
ADHD, mandating careful differential and/or addi-
tional diagnosis, particularly given the high risk for
self-harm in females with ADHD.
Clinical vs. representative samples
Biases accrue from making generalizations about
causal mechanisms, symptom profiles, or treatment
responses in clinically referred versus nonreferred/
population-based samples (Goodman et al., 1997;
LeWinn, Sheridan, Keyes, Hamilton, & McLaughlin,
2017). As highlighted below, conclusions about sex
differences in levels of ADHD-related symptoms
and/or impairments can differ dramatically depend-
ing on referral source.
Comorbidity and associated psychopathology
Individuals with any given mental condition are
highly likely to experience additional syndromes
(Angold, Costello, & Erkanli, 1999; Caron & Rutter,
1991). By definition, such comorbidity comprises the
joint presence of two or more independent manifes-
tations of psychopathology. Yet the extraordinarily
high rates of comorbidity – far above levels pre-
dictable if the underlying conditions were truly
independent – lend strong suspicion to the idea that
other mechanisms are at play. Supposedly indepen-
dent disorders may be linked in terms of risk factors
and even symptoms. Moreover, a general liability to
all forms of mental disorder is increasingly investi-
gated, with respect to the so-called general psy-
chopathology (or ‘p’) factor (e.g., Caspi et al., 2014).
Finally, what appears to be the sequential presence
of different categorical diagnoses – for example, from
early ADHD to later conduct disorder, followed by
substance use disorders and adult antisocial per-
sonality disorder for males and self-harmful behav-
iors and adult borderline personality disorder for
females (e.g., Beauchaine, Hinshaw, & Bridge, 2019)
– may actually reflect heterotypic continuity (Hin-
shaw, 2017). This concept denotes the stability of an
underlying predisposition that yields changing
4 Stephen P. Hinshaw et al.
symptoms across development as the result of a
range of biological and contextual forces.
Heritable and psychosocial influences
Genetically informative investigations reveal that
ADHD, appraised dimensionally or categorically, is
strongly heritable (e.g., Faraone & Larsson, 2019;
Thapar, 2018; for an informative review of potential
genetic and endocrine mechanisms potentially
underlying sex differences, see Davies, 2014). Yet
high heritability does not imply that symptom
presentation and/or impairment are devoid of
environmental input (e.g., Lahey, 2021). Indeed,
extreme environmental deprivation may engender
inattention and overactivity (usually linked with
highly aberrant attachment; see Kreppner,
O’Connor, & Rutter, 2001). In more typical cases,
negative parent–child interactions often maintain
and exacerbate heritable tendencies toward impul-
sivity and dysregulation (Beauchaine & McNulty,
2013), even in adoptive families (Sellers et al., 2021).
For girls with ADHD, parenting stress related to
caring for such a daughter can magnify the under-
lying tendencies and predict subsequent impairment
in adolescence and beyond (Gordon & Hinshaw,
2017).
Nonheritable biological risk factors – such as
prenatal maternal alcohol or nicotine use, low
birthweight, or exposure to toxic substances early
in life – are implicated in some cases of ADHD.
Genetic vulnerability may well statistically interact
with environmental triggers in the genesis of signif-
icant symptoms; inflammatory processes may also
play a role (Nigg et al., 2020). All too little research
exists on sex differences in the unfolding of such
transactional processes (see Martin et al., 2018, for
findings related to common- versus rare-variant
genotypes in males versus females). Important
intraindividual mechanisms linked to ADHD – dys-
regulated attention, poor executive functions (e.g.,
working memory, response inhibition), low intrinsic
motivation, and emotion dysregulation (for at least a
subgroup) – are well established (Sonuga-Barke &
Halperin, 2010). Still, most of the relevant research
emanates from predominantly or exclusively male
samples.
Loyer Carbonneau, Demers, Bigras, and Guay
(2020) provided a comprehensive meta-analysis of
symptoms and underlying mechanisms related to
sex differences in youth with ADHD. In short,
objective indicators revealed that boys show greater
hyperactivity than girls but statistically equivalent
levels of inattention. Yet teachers rate boys as higher
on both, with the clear implication that adult ratings
may lead to underreporting and underdiagnosis of
ADHD in girls (see Abikoff, Courtney, Pelham, &
Koplewicz, 1993, regarding halo effects in adult
informant ratings). Regarding executive functions,
girls with ADHD have, on average, greater cognitive
flexibility, and better motor response inhibition than
boys, although the sexes are similar with respect to
interference control and working memory (Loyer
Carbonneau et al., 2020). Overall, it is essential to
examine sex differences in, and female-specific
manifestations of, both symptoms/impairments
and mechanistic processes.
Girls with ADHD: what do we know?
Pioneering work in the systematic investigation of
females with ADHD began four decades ago (e.g.,
Ackerman, Sykman, & Oglesby, 1983; Kashani,
Chapel, Ellis, & Shekim, 1979; for other early
empirical studies, see Berry, Shaywitz, & Shaywitz,
1985; Biederman et al., 1994; James & Taylor, 1990;
Mannuzza & Gittelman, 1984; McGee & Feehan,
1991). Because many mixed-sex samples had extre-
mely small female subsamples (e.g., Barkley, Fis-
cher, Smallish, & Fletcher, 2002), calls for focus on
girls and women with ADHD have continued (Bark-
ley, 2002; Nussbaum, 2012; Quinn & Madhoo,
2014; Staller & Faraone, 2006).
Key reasons for the longstanding underrepresen-
tation of females with ADHD include the following:
(a) long-term scientific/professional insistence that
the condition was vanishingly rare in girls (and even
more so in women, as ADHD was assumed to be
childhood-limited); (b) predominance of the inatten-
tive (and less visibly impairing) presentation in
females (e.g., Biederman et al., 2002; Lahey et al.,
1994); (c) lower rates of co-occurring disruptive
behavior disorders in girls or later onset of such
(Uchida et al., 2018), suppressing the visibility and
salience of female symptoms (Mowlem, Rosenqvist,
et al., 2019); (d) clinician bias that ADHD symptoms
are indicative of the diagnosis in boys but not girls
(Bruchm€ uller, Margraf, & Schneider, 2012); (e) the
finding that parent and teacher ratings systemati-
cally underreport female, as opposed to male, ADHD
behavior patterns, even when objectively observed
behaviors are matched between the sexes (Meyer,
Stevenson, & Sonuga-Barke, 2020); and (f) higher
rates of compensatory behaviors in females (Mow-
lem, Agnew-Blais, Agnew-Blais, Taylor, & Asherson,
2019). We selectively review findings in childhood
through mid-adolescence.
In an intriguing early study, James and Taylor
(1990) extracted a small sample of 61 boys and 18
girls with diagnosed hyperkinetic disorder – a
diagnosis far more stringent than the current ADHD
criteria – from a large clinical sample. The female
subsample was overrepresented with language dis-
orders and low IQ scores compared with the male
subsample (see Berry et al., 1985, who also found
greater peer rejection in their female sample; see
also Rokeach & Wiener, 2018, regarding relation-
ship quality in female vs. male adolescents with
ADHD). Such a pattern is just what would be
predicted from the constitutional variability model.
© 2021 Association for Child and Adolescent Mental Health.

Yet clinical samples are, by definition, not repre-
sentative of the population (Goodman et al., 1997).
The importance of sampling issues cannot be over-
stated: The important, early meta-analytic reviews of
sex differences in ADHD (Gaub & Carlson, 1997;
Gershon, 2002) gave ample evidence that the type of
sample investigated (clinical versus nonre-
ferred/community) had considerable effect on con-
clusions. Gaub and Carlson (1997) found that,
overall, boys display greater symptom severity and
externalizing comorbidity levels than girls, whereas
the latter reveal greater cognitive impairments. Yet
both referral source and informant (e.g., parent vs.
teacher) were crucial moderators, as opposite pat-
terns of findings for the two types of samples and
raters sometimes emerged. Additional clinical sam-
ples yield contradictory outcomes regarding whether
girls with ADHD have equivalent social impairment
as boys (Greene et al., 2001) or greater social/
academic deficits (Rucklidge & Tannock, 2001; see
also Elkins, Malone, Keyes, Iacono, & McGue, 2011).
If girls with ADHD actually have fewer/less severe
symptoms than boys, a core tenet of the gender
paradox would be violated, obviating the need for
polygenetic multiple threshold versus constitutional
variability explanations.
A major step forward occurred via the Mas-
sachusetts General Hospital (MGH) studies of boys
and girls with ADHD (see Uchida et al., 2018, for
review of relevant publications). Both boys and girls
with ADHD and those without (all aged 6–17 years)
were recruited from psychiatric and pediatric refer-
ral sources and followed over time. Note that the
sample was predominantly White and initially
diagnosed using DSM-III-R criteria, but important
methodological advantages (e.g., blinded assess-
ments, ascertainment of familiality, measures of
educational and cognitive functioning beyond
symptoms/diagnoses per se) yielded crucial find-
ings. Indeed, in this unprecedentedly large sample
of carefully diagnosed girls with ADHD (n = 140),
comorbidities and impairments were clearly evi-
dent, belying the view that ADHD was nonexistent
or of trivial importance for females. In fact, func-
tional impairment levels matched those of their
male ADHD sample, as did rates of comorbid
disorders (although girls showed later onset of
disruptive behavior problems; Biederman et al.,
1994). Most female impairments were evident when
covarying comorbid conditions, signaling that
ADHD itself predicted impairment.
An equal-sized sample of ethnically and socioeco-
nomically diverse girls with ADHD aged 6–12 years
at baseline – plus 88 age- and ethnicity-matched
comparison girls – was described in Hinshaw (2002)
and Hinshaw, Carte, Sami, Treuting, and Zupan
(2002). Participants were carefully diagnosed with
ADHD using DSM-IV criteria and took part in a 5-
week naturalistic research summer program, afford-
ing behavioral observations and peer sociometric
© 2021 Association for Child and Adolescent Mental Health.
ADHD in girls and women 5
nominations in addition to adult informant reports
and individualized testing data (the investigation is
termed the Berkeley Girls with ADHD Longitudinal
Study, or BGALS). In relation to the comparison
group, the ADHD participants were impaired in all
domains of measured functioning (e.g., symptoms,
associated psychopathology, family stress, peer rela-
tionships, academics, neuropsychological measures,
use of special services, self-perceptions), with effect
sizes ranging from medium to extremely large. Find-
ings held with stringent covariation of demographic
and cognitive factors and, in most cases, comorbidi-
ties. In the first systematic contrast of Inattentive
versus Combined presentations in girls, both sub-
groups were highly impaired in relation to the
comparison participants but differed significantly
from each other only for externalizing behaviors and
peer rejection, with the Combined subgroup scoring
higher for each. Five-year prospective follow-up into
middle adolescence (Hinshaw, Carte, Fan, Jassy, &
Owens, 2007; Hinshaw, Owens, Sami, & Fargeon,
2006) revealed enduring impairment in all domains
examined. Additionally, the proportion of the ADHD
sample meeting criteria for overall positive adjust-
ment was distressingly low (Owens, Hinshaw, Lee, &
Lahey, 2009). Selected additional findings from
BGALS data are reviewed in Owens et al. (2017).
In a large community survey of girls meeting
criteria for hyperactivity, conduct problems, or both,
followed from childhood to mid-adolescence, Young,
Heptinstall, Sonuga-Barke, Chadwick, and Taylor
(2005) found that hyperactivity was particularly
predictive of pervasive adolescent academic and
interpersonal problems. Lahey et al. (2007) found
that ADHD in preschool predicted subsequent early-
adolescent comorbidities in both sexes, with predic-
tions to internalizing comorbidities especially strong
for girls.
Overall: First, sex ratios reveal a male predomi-
nance of over 2:1 for ADHD in childhood and
adolescence (Danielson et al., 2018). Second, subtle
yet important differences in symptoms exist, with
respect, for example, to greater verbal overactivity
in females versus physical overactivity in males
(Young et al., 2020). Also, many girls with ADHD,
particularly those with predominant inattention,
may compensate with intensive effort and coping
strategies (including family coping), masking key
impairments and lowering the chance for recogni-
tion (Mowlem, Agnew-Blais, et al., 2019). Third,
comorbidity (regarding categorical diagnoses) and
associated features (regarding dimensional vari-
ables) differ, as males reveal stronger linkages with
externalizing problems (at least in childhood) and
females with internalizing problems and possibly
language disorders and neurological problems (e.g.,
Tung et al., 2016). Fourth, ADHD is highly impair-
ing in girls during childhood and adolescence
regarding major domains of life functioning (Hin-
shaw, 2018).
6 Stephen P. Hinshaw et al.
Developmental progressions, mediators, and
heterotypic continuity by adulthood
The core questions here pertain to outcomes encoun-
tered by girls with ADHD by adulthood, along with
childhood predictor variables and adolescent medi-
ator processes that may presage long-term impair-
ments. We also summarize selected cross-sectional
investigations of women with ADHD. Some studies of
quite-small female subsamples have yielded
provocative exploratory findings (e.g., Barkley
et al., 2002; Sarver, McCart, Sheidow, & Letourneau,
2014). Additionally, Babinski et al. (2010) followed
34 young women with childhood-diagnosed ADHD
and 24 without, to the end of adolescence. ADHD-
related impairments emerged for some domains (e.g.,
conflict with parents, depression, fewer romantic
relationships) but not for others (e.g., job perfor-
mance, substance use).
In the MGH sample, follow-up revealed continuing
symptoms and impairments in girls with carefully
diagnosed baseline ADHD (Biederman et al., 2010;
see also Biederman et al., 2006). Although half or
fewer of such participants met full diagnostic crite-
ria by early adulthood, over two-thirds revealed
above-normative symptom levels plus clear func-
tional impairments (Uchida et al., 2018; see also
Owens et al., 2017; Sibley et al., 2021). As for
comorbid disorders, Biederman et al. (2010) demon-
strated that rates of antisocial, mood, anxiety,
developmental, addictive, and eating disorders were
substantially elevated beyond those of the compar-
ison participants. Furthermore, compared with the
MGH males who also were followed longitudinally,
the female sample showed lower rates of adult
antisocial behaviors but higher rates of mood and
anxiety disorders. Executive functioning perfor-
mance was also compromised (Seidman et al.,
2006). These findings withstood stringent statistical
adjustment for potentially confounding variables
(see Mick et al., 2011, for data on predictors of
follow-up status).
In the BGALS follow-ups through an average age of
20 (Hinshaw et al., 2012) and then 26 years (Owens
et al., 2017) – for which participant retention rates
ranged from 93% to 95% – the focus was on
functional impairments. Findings revealed large
and statistically significant impairment relative to
the comparison sample, even with stringent statisti-
cal adjustment for demographic and cognitive fac-
tors. Noteworthy were academic underperformance
(especially in mathematics), internalizing disorders,
poor executive functions (Gordon & Hinshaw, 2020),
employment-related problems, unplanned preg-
nancy rates (43% in the ADHD sample versus 11%
of comparisons), high risk for intimate partner
violence (Guendelman, Ahmad, Ahmad, Meza,
Owens, & Hinshaw, 2016), and early engagement
in oral sex (Halkett & Hinshaw, 2021). Yet evidence
for beyond-normative substance use problems (ex-
cept nicotine), driving problems, and eating prob-
lems was not found.
Other investigations corroborate serious impair-
ment. In a relatively early longitudinal study, Dals-
gaard, Mortensen, Frydenberg, and Thomsen (2002)
discovered that girls with ADHD (especially those
with comorbid conduct problems) had significantly
higher risk than parallel boys for subsequent adult
inpatient psychiatric admissions. In a large Norwe-
gian investigation of women and men with ADHD in
adulthood, Fredriksen et al. (2014) found larger
incidence of lifetime work-related disability in the
female subsample; inattentive symptoms were espe-
cially predictive of such difficulties. Furthermore,
marked risk for teen motherhood – 15% for females
with ADHD versus 3% for comparisons – was
revealed in the Swedish cohort study of Skoglund
et al. (2019), who also found elevated prenatal and
perinatal complications related to those births.
Given its rising rates (especially in females) and clear
public-health importance, we focus on self-harm,
including nonsuicidal self-injury (NSSI) and suicidal
behavior. Population studies have revealed a sizable
risk for such behaviors among individuals with ADHD
(Chen et al., 2014; Hurtig, Taanila, Moilanen, Nord-
str€
om, & Ebeling, 2012; see review in Garas & Bal azs,
2020). As for longitudinal findings, Chronis-Tuscano
et al. (2010) found that, among preschoolers with
ADHD reassessed in early to late adolescence, rates of
depression and suicide attempts were elevated in
relation to comparison youth, despite stringent use of
covariates. Crucially, these rates were significantly
higher in the female compared with male subsample.
In more recent research, women with ADHD had
particularly high rates of NSSI (Bal azs, Gy}
ori, Horv
ath,
Meszaros, & Szentiv anyi, 2018), suicidal ideation
(Babinski, Neely, Ba, & Liu, 2020), and suicidal
behavior (Fitzgerald, Dalsgaard, Nordentoft, & Erlang-
sen, 2019), even as compared with their male coun-
terparts.
For the initial BGALS indication of increased risk
for self-harm, Hinshaw et al. (2012). reported that,
by early adulthood, girls with childhood ADHD-
Combined (but not Inattentive) presentation had
markedly higher rates of attempted suicide (22%
for ADHD-C, 8% for ADHD-I, and 6% for compar-
isons) and moderate-to-severe NSSI (51%, 29%, and
19%, respectively), even with stringent use of key
covariates (see also Owens et al., 2017). A series of
theoretically driven mediator analyses followed. (a)
Swanson, Owens, and Hinshaw (2014) found that
early-to-mid-adolescent internalizing behaviors (as
reported by parents, teachers, and participants)
significantly and partially mediated the link between
childhood ADHD and subsequent suicide attempts,
but adolescent externalizing behaviors (parent- and
teacher-reported) and an objective indicator of poor
executive functioning were parallel mediators of
© 2021 Association for Child and Adolescent Mental Health.

NSSI. (b) Regarding peer relationships, Meza,
Owens, and Hinshaw (2016) reported that teacher-
reported peer rejection in adolescence significantly
and partially mediated the link to subsequent sui-
cide attempts, whereas self-reported peer victimiza-
tion mediated the link to NSSI. (c) As for
maltreatment, Guendelman, Owens, Owens, Galan,
Gard, and Hinshaw (2016) utilized multi-informant,
blinded ratings of each BGALS participant for evi-
dence of physical abuse, sexual abuse, and/or
neglect in childhood through early adolescence. For
one thing, ADHD participants showed greater inci-
dence of maltreatment than the comparisons. Next,
and crucially, among ADHD participants the experi-
ence of one or more forms of such maltreatment
predicted both depression and elevated risk for
suicide attempts by early adulthood. In fact, the rate
of such attempts was over 33% for participants with
childhood ADHD who had also experienced one or
more forms of maltreatment. In short, the combina-
tion of maltreatment and highly heritable ADHD
symptoms was linked to an extraordinarily high risk
for suicidal behavior – paralleling work on bipolar
disorder, also highly heritable, for which maltreat-
ment predicts heightened risk of suicidality (Brown,
McBride, Bauer, & Williford, 2005). In short, reduc-
tionistic accounts of relevant risk as either exclu-
sively heritable or exclusively contextual are not
accurate.
Meza, Owens, and Hinshaw (2020) examined
childhood predictors of NSSI, suicidal ideation, and
suicide attempts in BGALS participants followed
through their mid-20s. Key predictors of NSSI were
childhood ADHD symptoms, externalizing behaviors,
poor executive functioning, and participant percep-
tions of paternal (but not maternal) negative parent-
ing. The significant childhood predictors of suicidal
ideation were low perceived self-competence and a
history of adverse child experiences; for attempted
suicide, the significant predictors were elevated-
childhood ADHD symptoms (both inattention and
hyperactivity-impulsivity), adverse childhood expe-
riences, and low perceived self-competence. Interac-
tions between predictor variables emerged,
indicating moderation effects. For example, regard-
ing lifetime NSSI, 80% of participants with this form
of self-injury had childhood externalizing and inter-
nalizing scores in the clinical range plus poor child-
hood executive functioning.
In short, for substantial numbers of girls with
ADHD, a heterotypically continuous trajectory from
early impulsivity (and in some cases, high levels of
concurrent early inattention) is salient. Associated
psychopathology (internalizing and/or externaliz-
ing), executive dysfunction, maltreatment or other
early adverse experiences, negative father–daughter
interactions, low self-worth, and peer victimization/
rejection are implicated. Such process-oriented find-
ings may aid with intervention (see O’Grady &
Hinshaw, 2021, for commentary).
© 2021 Association for Child and Adolescent Mental Health.
ADHD in girls and women 7
Regarding unplanned pregnancy, Owens and Hin-
shaw (2020) found that mid-adolescent academic
underachievement was part of a serial mediation
pathway, whereby childhood ADHD predicted low
academic performance in mid-adolescence, which in
turn mediated late-adolescent engagement in risky
sexual behavior, with resultant high rates of
unplanned pregnancy. In addition, low academic
performance in adolescence mediated the linkage
between childhood ADHD and the later experience of
intimate partner violence (Guendelman, Ahmad,
et al., 2016).
Finally, Owens and Hinshaw (2016) presented a
complex set of serial, indirect effect, mediator mod-
els, from childhood neurocognitive vulnerability
through early- and late-adolescent psychological
processes and then to internalizing/externalizing
comorbidity in adulthood. Such comorbidity was
marked by adolescent paths incorporating (a) poor
self-control/delay of gratification and (b) academic
underachievement/school failure. In all, relevant
developmental processes for females are variegated,
embedded in intraindividual, family-related, and
school contexts.
Unresolved issues and core recommendations
for future directions
Unresolved issues
First, given significant female impairments linked
with ADHD, a core issue is whether girls and women
should be diagnosed in relation to overall norms
(emanating from both males and females) versus
female-specific norms. With the latter, girls would
more easily meet symptom thresholds, as they would
be compared with the ‘lower bar’ of average female
levels of ADHD symptoms (Reid et al., 2000). A
parallel argument might be made for depression in
males: More men would be diagnosed if their symp-
toms were compared with male norms, partly
redressing the doubled female:male sex ratio for
depression that begins in adolescence. Yet we urge
caution. It would need to be definitively established
that girls qualifying for an ADHD diagnosis (or men,
for depression) on the basis of sex-specific norms
reveal clear impairments. Otherwise, rates of diag-
nosis in females with ADHD could become overin-
flated. In the absence of such evidence, it may be
preferable to ensure that (a) diagnostic items reflect
both male- and female-specific manifestations, (b)
subtle indicators of inattention/disorganization are
probed, and (c) clinicians inquire about such factors
as compensatory behaviors and life transitions in
girls and women (Young et al., 2020).
Second, we note that important issues of culture,
diversity, and stigma with regard to ADHD need
amplification. Despite critics’ contentions that
ADHD is an exclusive product of major pressures
for educational and vocational success, Western
8 Stephen P. Hinshaw et al.

culture, unresponsive schools (including compul- psychosocial interventions should be tailored to

sory education), or lax parenting, the relatively female-specific manifestations and sensibilities
consistent prevalence rates around the world (e.g., prioritizing group interventions, focusing on
(Polanczyk et al., 2007) and the strong contributions inattention and on relationship issues). A model
of psychobiological risk factors argue otherwise (for a intervention in this regard is the Child Life and
classic debate, see Timimi & Taylor, 2004). Still, Attention Skills curriculum, designed for both boys
rates and types of various treatments vary substan- and girls with the Inattentive presentation. It
tially around the world (Hinshaw et al., 2011). As revealed positive benefits in a randomized controlled
well, cultural and social forces markedly affect trial (Pfiffner et al., 2014). Finally, unless girls and
personal and family acceptance as well as adapta- women are accurately detected for ADHD during the
tion (Asherson et al., 2012) – as well as high rates of evaluation and diagnostic process, they may never
diagnosed prevalence in the United States (Hinshaw receive evidence-based treatments.
& Scheffler, 2014). Far too little is known about the
experience of ADHD in non-Western/post-industrial
cultures and in racial groups beyond Whites. Espe- Recommendations and brief research agenda
cially given increased recognition and diagnosis of
Based on the preceding review, we present a brief,
ADHD in Black youth (C enat et al., 2021) and lower-
bullet-point listing of recommended practices
SES individuals (Hinshaw & Scheffler, 2014), it is
regarding assessment and treatment, as well as
essential to include diverse participants in research
research priorities.
investigations, including girls and women with
Regarding evaluation and assessment:
ADHD beyond middle-class, majority individuals.
As for stigma, a review by Nguyen and Hinshaw
 The assumption that girls and women simply do
(2020) highlights considerable evidence for public
not exhibit ADHD – or do so only rarely – is no
stigma, internalized stigma, and associated stigma
longer tenable.
for youth and adults with ADHD (for a general
 A thorough, evidence-based evaluation is essen-
review, see Martinez & Hinshaw, 2016; for negative
tial, including assessment of comorbid behav-
adult attitudes regarding youth ADHD, see Pescoso-
ioral, emotional, and learning issues.
lido et al., 2008). Despite the belief that stigmatiza-
 Many assessment scales laden are with items
tion is reserved for psychotic conditions such as
emphasizing male forms of ADHD but do not
schizophrenia, it is highly likely that disorders
focus sufficiently on potential female-relevant
marked by inconsistency of performance, like ADHD,
behaviors (e.g., hyper-verbal behavior versus
can fuel harsh castigation – perhaps because of the
overly active physical behavior). Moreover, teach-
belief that insufficient effort is the underlying cause.
ers may underreport ADHD symptoms in girls.
Furthermore, for girls and women, traditionally
 Many girls with actual ADHD may be hard to
valued for social skills and cohesion, interpersonal
identify given their tendency to present with
difficulties related to ADHD may be particularly
exclusive inattention, relative lack of externaliz-
stigmatized (e.g., Blachman & Hinshaw, 2002).
ing behaviors, comorbid presence of anxiety and/
Third, space limitations preclude any kind of sys-
or depression, and use of compensatory strate-
tematic review of sex differences in ADHD-related
gies and family supports that may mask core
treatment response. Evidence does not reveal major
symptoms (see Young et al., 2020, who also
differences in female versus male responses to psy-
emphasize that highly structured environments
chosocial or pharmacologic interventions. In a recent
can mask ADHD).
review of medications, Kok, Groen, Fuermaier, and
 Times of life transition – to formal schooling,
Tucha (2020) found that girls with ADHD were less
secondary education, challenging university/
likely to be treated with medications than boys (see also
vocational venues; economic independence; and
Mowlem, Rosenqvist, et al., 2019), yet overall results
pregnancy/childbearing – may well be triggering
revealed sex-equivalent outcomes in response to med-
of symptom exacerbation. Thus, developmental
ication. Still, females appear to encounter more
histories are essential.
adverse reactions to stimulants and may respond
 Evaluation of strengths in the assessment pro-
preferentially to nonstimulants like selective nore-
cess is crucial, as their elucidation may be
pinephrine reuptake inhibitors. And, in the largest
important targets for treatment planning.
clinical trial ever conducted for children with ADHD,
including 20% girls among its 579 participants, both Regarding treatment:
behavioral and stimulant medication-related treat-
ment effects were not moderated by sex (MTA Cooper-  Families of girls with ADHD are marked by
ative Group, 1999). Yet female samples or subsamples stress, discordant parenting, and potential inval-
are sufficiently small in most investigations to preclude idation of their daughter (Beauchaine et al.,
detection of sex-specific findings. 2019; Gordon & Hinshaw, 2017). Parent man-
Authoritative sources such as Quinn and Madhoo agement interventions (including emotion regu-
(2014) and Young et al. (2020) caution that lation skills for parents), combined with school-

© 2021 Association for Child and Adolescent Mental Health.

 ADHD in girls and women 9

based programs and active promotion of social
skills, are evidence-based ideals.
 There are no definitive data that ADHD medica-
tions reveal greatly different effects in females
than males, although nonstimulants may be
indicted more in girls and women.
 Beyond symptom reduction, treatments should
emphasize academic engagement/skills, moni-
toring of peer interactions, reduction in risk for
maltreatment, and building of self-concept (not
falsely but through development of competen-
cies). Education around sexuality, protected sex,
and prevention of partner violence are also
clearly in order.
In terms of research priorities:
 A key direction should be not only more precise
estimates of sex differences in symptoms and
impairments but also female-specific elucidation
of heterotypically continuous developmental
pathways to self-harm, relationship difficulties,
unplanned pregnancy, and subsequent parent-
ing of the next generation. Although expensive,
prospective longitudinal research is necessary for
such elucidation.
 Greater female representation (of both parents
and offspring) is needed in genetic and epigenetic
investigations; in follow-up of prenatal and peri-
natal risk factors; and in studies of the roles of
parenting practices, parenting stress, and par-
ental psychopathology. Also, studies of biological
and psychosocial changes related to transitions
to puberty and subsequently to childbirth and
childrearing – as well as perimenopause and
menopause in women – are sorely needed.
 In the transition to adolescence and adulthood,
self-report is more widely utilized for assessment
than exclusively informant report. Additional
research is needed on the validity of self-report,
particularly for adolescent girls and women. It
may be that female self-report is more accurate
than that of men, with implications for the
decreasing sex ratio of ADHD diagnosis by
adulthood.
 Determination of later life health risks, including
neurodegenerative disorders – along with rele-
vant underlying mechanisms – is a priority. Far
too little is known about such topics, particularly
in women.
In closing, we hope that our review has highlighted
the importance of ADHD in girls and women, the
ways in which the historical neglect of this popula-
tion has at last inspired renewed research and
clinical efforts, and the importance of examining
female-specific mechanisms and trajectories beyond
the search for sex differences per se. There is much
to gain, scientifically and clinically, by full represen-
tation of the sexes (as well as other crucial individual
and cultural differences) in future efforts within this
and other domains of psychopathology.
Acknowledgements
The authors have declared that they have no competing
or potential conflicts of interest.
Correspondence
Stephen P. Hinshaw, University of California, Berkeley,
California, USA; Email: hinshaw@berkeley.edu

Key points

 Until recently, almost all research on ADHD has focused on boys and men, with female presentations having
been largely overlooked in both clinical and research settings.
 In childhood, the prevalence of ADHD in boys is 2–2.5 times higher than its prevalence in girls. By adulthood,
this ratio becomes closer to equal.
 Females are more likely to present inattention symptoms and associated internalizing problems, whereas
males are more likely to display hyperactive-impulsive symptoms and associated externalizing problems.
 ADHD is highly impairing in girls during childhood and adolescence regarding major domains of life
functioning, with longitudinal studies showing these impairments to persist through adulthood. Notably,
self-harm continues to be a major impairment in girls and women with ADHD throughout adolescence and
adulthood.
 Ongoing efforts exploring developmental pathways and casual mechanisms linking female presentation of
ADHD to long-term outcomes will further scientific understanding and foster responsive interventions.

References Ackerman, P.T., Sykman, P.A., & Oglesby, D.M. (1983). Sex
Abikoff, H., Courtney, M., Pelham, W.E., & Koplewicz, H.S. (1993). and group differences in reading and attention disordered
Teachers’ ratings of disruptive behaviors: The influence of halo children with and without hyperkinesis. Journal of Learning
effects. Journal of Abnormal Child Psychology, 21, 519–533. Disabilities, 16, 407–415.

© 2021 Association for Child and Adolescent Mental Health.

10 Stephen P. Hinshaw et al.
Angold, A., Costello, E.J., & Erkanli, A. (1999). Comorbidity.
Journal of Child Psychology and Psychiatry, 40, 57–87.
Asherson, P., & Agnew-Blais, J. (2019). Annual Research
Review: Does late-onset attention-deficit/hyperactivity dis-
order exist? Journal of Child Psychology and Psychiatry, 60,
333–352.
Asherson, P., Akehurst, R., Kooij, J.J., Huss, M., Beusterien,
K., Sasan e, R., . . . & Hodgkins, P. (2012). Under diagnosis of
adult ADHD: Cultural influences and societal burden.
Journal of Attention Disorders, 16(5_Suppl), 20S–38S.
Babinski, D.E., Neely, K.A., Ba, D.M., & Liu, G. (2020).
Depression and suicidal behavior in young adult men and
women with ADHD: Evidence from claims data. Journal of
Clinical Psychiatry, 81, 19m13130.
Babinski, D.E., Pelham, W.E., Molina, B.S.G., Gnagy, E.M.,
Waschbusch, D.A., Yu, J., . . . & Karch, K.M. (2010). Late
adolescent and young adult outcomes of girls diagnosed
with ADHD in childhood: An exploratory investigation.
Journal of Attention Disorders, 15, 204–214.
Bal
azs, J., Gy} ori, D., Horv ath, L.O., Meszaros, G., & Szen-
tiv
anyi, D. (2018). Attention-deficit hyperactivity disorder
and nonsuicidal self-injury in a clinical sample of adoles-
cents: the role of comorbidities and gender. BMC Psychiatry,
18, 34.
Barkley, R.A. (2002). Major life activity and health outcomes
associated with attention- deficit/hyperactivity disorder.
Journal of Clinical Psychiatry, 63(Suppl 12), 10–15.
Barkley, R.A., Fischer, M., Smallish, L., & Fletcher, K. (2002).
The persistence of attention-deficit/hyperactivity disorder
into young adulthood as a function of reporting source and
definition of disorder. Journal of Abnormal Psychology, 111,
279–289.
Beauchaine, T.P., Hinshaw, S.P., & Bridge, J.A. (2019). Non-
suicidal self-injury and suicidal behaviors in girls: The case
for targeted prevention in preadolescence. Clinical Psycho-
logical Science, 7, 643–667.
Beauchaine, T.P., & McNulty, T. (2013). Comorbidities and
continuities as ontogenic processes: toward a developmental
spectrum model of externalizing psychopathology. Develop-
ment and Psychopathology, 25(4pt2), 1505–1528.
Beery, A.K., & Zucker, I. (2011). Sex bias in neuroscience and
biomedical research. Neuroscience & Biobehavioral Reviews,
35, 565–572.
Berry, C.A., Shaywitz, S.E., & Shaywitz, B.A. (1985). Girls with
attention deficit disorder: A silent minority? A report on
behavioral and cognitive characteristics. Pediatrics, 76, 801–
809.
Biederman, J., Faraone, S.V., Spencer, T., Wilens, T., Mick, E.,
& Lapey, K.A. (1994). Gender differences in a sample of
adults with attention deficit hyperactivity disorder. Psychi-
atry Research, 53, 13–29.
Biederman, J., Mick, E., Faraone, S.V., Braaten, E., Doyle, A.,
Spencer, T., . . . & Johnson, M.A. (2002). Influence of gender
on attention deficit hyperactivity disorder in children
referred to a psychiatric clinic. American Journal of Psychi-
atry, 159, 36–42.
Biederman, J., Monuteaux, M.C., Mick, E., Spencer, T.,
Wilens, T.E., Klein, K.L., . . . & Faraone, S.V. (2006).
Psychopathology in females with attention-deficit/
hyperactivity disorder: A controlled, five-rear prospective
study. Biological Psychiatry, 60, 1098–1105.
Biederman, J., Petty, C.R., Monuteaux, M.C., Fried, R., Byrne,
D., Mirto, T., . . . & Faraone, S.V. (2010). Adult psychiatric
outcomes of girls with attention deficit hyperactivity disor-
der: 11-year follow-up in a longitudinal case-control study.
American Journal of Psychiatry, 167, 409–417.
Blachman, D.R., & Hinshaw, S.P. (2002). Patterns of friendship in
girls with and without attention-deficit/hyperactivity disorder.
Journal of Abnormal Child Psychology, 30, 625–640.
Brown, G.R., McBride, L., Bauer, M.S., & Williford, W.O.
(2005). Impact of childhood abuse on the course of bipolar
disorder: A replication study in U.S. veterans. Journal of
Affective Disorders, 89, 57–67.
Bruchm€ uller, K., Margraf, J., & Schneider, S. (2012). Is ADHD
diagnosed in accord with diagnostic criteria? Overdiagnosis
and influence of client gender on diagnosis. Journal of
Consulting and Clinical Psychology, 80, 128–138.
Caron, C., & Rutter, M. (1991). Comorbidity in child psy-
chopathology: Concepts, issues and research strategies.
Journal of Child Psychology and Psychiatry, 32, 1063–1080.
Caspi, A., Houts, R.M., Belsky, D.W., Goldman-Mellor, S.J.,
Harrington, H., Israel, S., . . . & Moffitt, T.E. (2014). The p factor:
One general psychopathology factor in the structure of psychi-
atric disorders? Clinical Psychological Science, 2, 119–137.
Caye, A., Petresco, S., de Barros, A.J.D., Bressan, R.A.,
Gadelha, A., Goncß alves, H., . . . & Rohde, L.A. (2020). Relative
age and attention-deficit/hyperactivity disorder: Data from
three epidemiological cohorts and a meta-analysis. Journal
of the American Academy of Child & Adolescent Psychiatry,
59, 990–997.
C
enat, J.M., Blais-Rochette, C., Morse, C., Vandette, M.P.,
Noorishad, P.G., Kogan, C., . . . & Labelle, P.R. (2021). Preva-
lence and risk factors associated with attention-deficit/
hyperactivity disorder among US Black individuals: A system-
atic review and meta-analysis. JAMA Psychiatry, 78, 21–28.
Chen, Q., Sjolander, A., Runeson, B., D’Onofrio, B.M., Licht-
enstein, P., & Larsson, H. (2014). Drug treatment for
attention-deficit/hyperactivity disorder and suicidal behav-
ior: Register based study. British Medical Journal, 348,
g3769.
Chronis-Tuscano, A., Molina, B.S., Pelham, W.E., Applegate,
B., Dahlke, A., Overmyer, M., & Lahey, B.B. (2010). Very
early predictors of adolescent depression and suicide
attempts in children with attention-deficit/hyperactivity
disorder. Archives of General Psychiatry, 67, 1044–1051.
Cuthbert, B.N., & Insel, T.R. (2013). Toward the future of
psychiatric diagnosis: The seven pillars of RDoC. BMC
Medicine, 11, 126.
Dalsgaard, S., Mortensen, P.B., Frydenberg, M., & Thomsen,
P.H. (2002). Conduct problems, gender and adult psychi-
atric outcome of children with attention-deficit hyperactivity
disorder. British Journal of Psychiatry, 181, 416–421.
Danielson, M.L., Bitsko, R.H., Ghandour, R.M., Holbrook, J.R.,
Kogan, M.D., & Blumberg, S.J. (2018). Prevalence of parent-
reported ADHD diagnosis and associated treatment among
U.S. children and adolescents, 2016. Journal of Clinical
Child and Adolescent Psychology, 47, 199–212.
Davies, W. (2014). Sex differences in Attention Deficit Hyper-
activity Disorder: Candidate genetic and endocrine mecha-
nisms. Frontiers in Endocrinology, 35, 331–346.
D€
opfner, M., Hautmann, C., G€ ortz-Dorten, A., Klasen, F.,
Ravens-Sieberer, U., & BELLA Study Group (2015). Long-
term course of ADHD symptoms from childhood to early
adulthood in a community sample. European Child &
Adolescent Psychiatry, 24, 665–673.
Eagly, A.H., Eaton, A., Rose, S.M., Riger, S., & McHugh, M.C.
(2012). Feminism and psychology: Analysis of a half-century
of research on women and gender. American Psychologist,
67, 211–230.
Elkins, I.J., Malone, S., Keyes, M., Iacono, W.G., & McGue, M.
(2011). The impact of attention-deficit/hyperactivity disor-
der on preadolescent adjustment may be greater for girls
than for boys. Journal of Clinical Child & Adolescent
Psychology, 40, 532–545.
Eme, R.F. (1979). Sex differences in childhood psychopathol-
ogy: A review. Psychological Bulletin, 86, 574–595.
Eme, R.F. (1992). Selective females affliction in the develop-
mental disorders of childhood: A literature review. Journal of
Clinical Child Psychology, 21, 354–364.
Faraone, S.V., & Larsson, H. (2019). Genetics of attention
deficit hyperactivity disorder. Molecular Psychiatry, 24, 562–
575.
© 2021 Association for Child and Adolescent Mental Health.

Fitzgerald, C., Dalsgaard, S., Nordentoft, M., & Erlangsen, A.
(2019). Suicidal behaviour among persons with attention-
deficit hyperactivity disorder. British Journal of Psychiatry,
215, 615–620.
Fredriksen, M., Dahl, A.A., Martinsen, E.W., Klungsoyr, O.,
Faraone, S.V., & Peleikis, D.E. (2014). Childhood and
persistent ADHD symptoms associated with educational
failure and long-term occupational disability in adult ADHD.
ADHD Attention Deficit and Hyperactivity Disorders, 6, 87–
99.
Fulton, B.D., Scheffler, R.M., & Hinshaw, S.P. (2015). State
variation in increased ADHD prevalence: Links to NCLB
school accountability and state medication laws. Psychiatric
Services, 66, 1074–1082.
Garas, P., & Bal azs, J. (2020). Long-term suicide risk of
children and adolescents with attention deficit and hyper-
activity disorder: A systematic review. Frontiers in Psychia-
try, 11, 557909.
Gaub, M., & Carlson, C.L. (1997). Gender differences in ADHD:
A meta-analysis and critical review. Journal of the American
Academy of Child & Adolescent Psychiatry, 36, 1036–1045.
Gentile, D.A. (1993). Special Section: Sex or gender? Technical
commentary: Just what are sex and gender anyway? A call
for a new terminological standard. Psychological Science, 4,
120–122.
Gershon, J., & Gershon, J. (2002). A meta-analytic review of
gender differences in ADHD. Journal of Attention Disorders,
5, 143–154.
Goodman, S.H., Lahey, B.B., Fielding, B., Dulcan, M., Narrow,
W., & Regier, D. (1997). Representativeness of clinical
samples of youths with mental disorders: A preliminary
population-based study. Journal of Abnormal Psychology,
106, 3–14.
Gordon, C.T., & Hinshaw, S.P. (2017). Parenting stress as a
mediator between childhood ADHD and early adult female
outcomes. Journal of Clinical Child and Adolescent Psychol-
ogy, 46, 588–599.
Gordon, C.T., & Hinshaw, S.P. (2020). Executive functions in
girls with and without childhood ADHD followed through
emerging adulthood: Developmental trajectories. Journal of
Clinical Child and Adolescent Psychology, 49, 509–523.
Great Britain Home Office. (2018). Inclusive by instinct:
Diversity and inclusion strategy 2018–2025. Available from:
https://assets.publishing.service.gov.uk/government/
uploads/system/uploads/attachment_data/file/739538/
Diversity_and_Inclusion_strategy_SCREEN.pdf [last
accessed 11 January 2021].
Greene, R.W., Biederman, J., Faraone, S.V., Monuteaux, M.C.,
Mick, E., DuPre, E.P., . . . & Goring, J.C. (2001). Social
impairment in girls with ADHD: Patterns, gender compar-
isons, and correlates. Journal of the American Academy of
Child and Adolescent Psychiatry, 40, 704–710.
Gualtieri, T., & Hicks, R.E. (1985). An immunoreactive theory
of selective male affliction. Behavioral and Brain Sciences, 8,
427–441.
Guelzow, B.T., Loya, F., & Hinshaw, S.P. (2017). How persis-
tent is ADHD into adulthood? Informant report and diag-
nostic thresholds in a female sample. Journal of Abnormal
Child Psychology, 45, 301–312.
Guendelman, M., Ahmad, S., Meza, J.I., Owens, E.B., &
Hinshaw, S.P. (2016). Childhood attention-deficit/
hyperactivity disorder predicts intimate partner victimiza-
tion in young women. Journal of Abnormal Child Psychology,
44, 155–166.
Guendelman, M., Owens, E.B., Galan, C., Gard, A., & Hinshaw,
S.P. (2016). Early adult correlates of maltreatment in girls with
ADHD: Increased risk for internalizing problems and suicidal-
ity. Development and Psychopathology, 28, 1–14.
Halkett, A., & Hinshaw, S.P. (2021). Initial engagement in oral
sex and sexual intercourse among adolescent girls with and
© 2021 Association for Child and Adolescent Mental Health.
ADHD in girls and women 11
without childhood attention-deficit/hyperactivity disorder.
Archives of Sexual Behavior, 50, 181–190.
Hartung, C.M., & Lefler, E.K. (2019). Sex and gender in
psychopathology: DSM-5 and beyond. Psychological Bul-
letin, 145, 390–409.
Hinshaw, S.P. (2002). Preadolescent girls with attention-
deficit/hyperactivity disorder: I. Background characteris-
tics, comorbidity, cognitive and social functioning, and
parenting practices. Journal of Consulting & Clinical Psy-
chology, 70, 1086–1098.
Hinshaw, S.P. (2017). Developmental psychopathology as a
scientific discipline: A twenty-first century perspective. In
T.P. Beauchaine, & S.P. Hinshaw (Eds.), Child and adoles-
cent psychopathology (3rd edn, pp. 3–32). Hoboken, NJ:
Wiley.
Hinshaw, S.P. (2018). Attention Deficit Hyperactivity Disorder
(ADHD): Controversy, developmental mechanisms, and mul-
tiple levels of analysis. Annual Review of Clinical Psychology,
14, 291–316.
Hinshaw, S.P., Carte, E.T., Fan, C., Jassy, J.S., & Owens, E.B.
(2007). Neuropsychological functioning of girls with
attention-deficit/hyperactivity disorder followed prospec-
tively into adolescence: Evidence for continuing deficits?
Neuropsychology, 21, 263–273.
Hinshaw, S.P., Carte, E.T., Sami, N., Treuting, J.J., & Zupan,
B.A. (2002). Preadolescent girls with attention- deficit/
hyperactivity disorder: II. Neuropsychological performance
in relation to subtypes and individual classification. Journal
of Consulting & Clinical Psychology, 70, 1099–1111.
Hinshaw, S.P., Owens, E.B., Sami, N., & Fargeon, S. (2006).
Prospective follow-up of girls with attention-deficit/
hyperactivity disorder into adolescence: Evidence for con-
tinuing cross-domain impairment. Journal of Consulting and
Clinical Psychology, 74, 489–499.
Hinshaw, S.P., Owens, E.B., Zalecki, C., Huggins, S.P.,
Montenegro-Nevado, A., Schrodek, E., & Swanson, E.N.
(2012). Prospective follow-up of girls with attention-deficit
hyperactivity disorder into young adulthood: Continuing
impairment includes elevated risk for suicide attempts and
self-injury. Journal of Consulting and Clinical Psychology,
80, 1041–1051.
Hinshaw, S.P., & Scheffler, R.M. (2014). The ADHD explosion:
Myths, medication, money, and today’s push for perfor-
mance. New York: Oxford University Press.
Hinshaw, S.P., Scheffler, R.M., Fulton, B.D., Aase, H.,
Banaschewski, T., Cheng, W., . . . & Weiss, M.D. (2011).
International variation in treatment procedures for
attention-deficit/hyperactivity disorder: Social context and
recent trends. Psychiatric Services, 62, 459–464.
Hurtig, T., Taanila, A., Moilanen, I., Nordstr€
om, T., & Ebeling,
H. (2012). Suicidal and self-harm behaviour associated with
adolescent attention deficit hyperactivity disorder—A study
in the Northern Finland Birth Cohort 1986. Nordic Journal of
Psychiatry, 66, 320–328.
James, A., & Taylor, E. (1990). Sex differences in the hyper-
kinetic syndrome of childhood. Journal of Child Psychology
& Psychiatry, 31, 437–446.
Kashani, J., Chapel, J.L., Ellis, J., & Shekim, W.O. (1979).
Hyperactive girls. Journal of Operational Psychiatry, 10,
145–148.
Kessler, R.C., Adler, L., Barkley, R., Biederman, J., Conners,
C.K., Demler, O., . . . & Zaslavsky, A.M. (2006). The preva-
lence and correlates of adult ADHD in the United States:
Results from the National Comorbidity Survey Replication.
American Journal of Psychiatry, 163, 716–723.
Kok, F.M., Groen, Y., Fuermaier, A.B., & Tucha, O. (2020). The
female side of pharmacotherapy for ADHD—A systematic
literature review. PLoS One, 15, e0239257.
Kreppner, J.M., O’Connor, T.G., Rutter, M., & English and
Romanian Adoptees Study Team (2001). Can inattention/
12 Stephen P. Hinshaw et al.
overactivity be an institutional deprivation syndrome? Jour-
nal of Abnormal Child Psychology, 29, 513–528.
Lahey, B.B. (2021). Dimensions of psychological problems:
Replacing diagnostic categories with a more science-based
and less stigmatizing alternative. New York: Oxford Univer-
sity Press.
Lahey, B.B., Applegate, B., McBurnett, K., Biederman, J.,
Greenhill, L., Hynd, G.W., . . . & Shaffer, D. (1994). DSM-IV
field trials for attention deficit hyperactivity disorder in
children and adolescents. American Journal of Psychiatry,
151, 1673–1685.
Lahey, B.B., Hartung, C.M., Loney, J., Pelham, W.E., Chronis,
A.M., & Lee, S.S. (2007). Are there sex differences in the
predictive validity of DSM–IV ADHD among younger chil-
dren? Journal of Clinical Child & Adolescent Psychology, 36,
113–126.
Larsson, H., Dilshad, R., Lichtenstein, P., & Barker, E.D.
(2011). Developmental trajectories of DSM-IV symptoms of
attention-deficit/ hyperactivity disorder: Genetic effects,
family risk, and associated psychopathology. Journal of
Child Psychology and Psychiatry, 52, 954–963.
LeWinn, K.Z., Sheridan, M.A., Keyes, K.M., Hamilton, A., &
McLaughlin, K.A. (2017). Sample composition alters associ-
ations between age and brain structure. Nature Communi-
cations, 8, 874.
Loeber, R., & Keenan, K. (1994). Interaction between conduct
disorder and its comorbid conditions: Effects of age and
gender. Clinical Psychology Review, 14, 497–523.
Loyer Carbonneau, M., Demers, M., Bigras, M., & Guay, M.-C.
(2020). Meta-analysis of sex differences in ADHD symptoms
and associated cognitive deficits. Journal of Attention Disor-
ders, Advance Online Publication. https://doi.org/10.
1177/1087054720923736
Mannuzza, S., & Gittelman, R. (1984). The adolescent outcome
of hyperactive girls. Psychiatry Research, 13, 19–29.
Martin, J., Walters, R.K., Demontis, D., Mattheisen, M., Lee,
S.H., Robinson, E., . . . & Werge, T. (2018). A genetic
investigation of sex bias in the prevalence of attention-
deficit/hyperactivity disorder. Biological Psychiatry, 83,
1044–1053.
Martinez, A., & Hinshaw, S.P. (2016). Mental health stigma:
Theory, developmental issues, and research priorities. In D.
Cicchetti (Ed.), Developmental psychopathology. Vol 4: Risk,
resilience, and intervention (3rd edn, pp. 997–1039). Hobo-
ken, NJ: Wiley.
Mazure, C.M., & Jones, D.P. (2015). Twenty years and still
counting: Including women as participants and studying sex
and gender in biomedical research. BMC Women’s Health,
15, 94.
McGee, R., & Feehan, M. (1991). Are girls with problems of
attention underrecognized? Journal of Psychopathology and
Behavioral Assessment, 13, 187–198.
Meyer, B.J., Stevenson, J., & Sonuga-Barke, E. (2020). Sex
differences in the meaning of parent and teacher ratings of
ADHD behaviors: An observational study. Journal of Atten-
tion Disorders, 24, 1847–1856.
Meza, J., Owens, E.B., & Hinshaw, S.P. (2016). Response
inhibition, peer preference and victimization, and self-harm:
Longitudinal associations in young adult women with and
without ADHD. Journal of Abnormal Child Psychology, 44,
323–334.
Meza, J.I., Owens, E.B., & Hinshaw, S.P. (2020). Childhood
predictors and moderators of lifetime risk of self-harm in
girls with and without attention-deficit/hyperactivity disor-
der. Development and Psychopathology, 1–17. Advance
online publication. https://doi.org/10.1017/
S0954579420000553
Mick, E., Byrne, D., Fried, R., Monuteaux, M., Faraone, S.V., &
Biederman, J. (2011). Predictors of ADHD persistence in
girls at 5-year follow-up. Journal of Attention Disorders, 15,
183–192.
Millenet, S., Laucht, M., Hohm, E., Jennen-Steinmetz, C.,
Hohmann, S., Schmidt, M.H., . . . & Zohsel, K. (2018). Sex-
specific trajectories of ADHD symptoms from adolescence to
young adulthood. European Child & Adolescent Psychiatry,
27, 1067–1075.
Mowlem, F., Agnew-Blais, J., Taylor, E., & Asherson, P. (2019).
Do different factors influence whether girls versus boys meet
ADHD diagnostic criteria? Sex differences among children with
high ADHD symptoms. Psychiatry Research, 272, 765–773.
Mowlem, F.D., Rosenqvist, M.A., Martin, J., Lichtenstein, P.,
Asherson, P., & Larsson, H. (2019). Sex differences in
predicting ADHD clinical diagnosis and pharmacological
treatment. European Child & Adolescent Psychiatry, 28,
481–489.
MTA Cooperative Group. (1999). Moderators and mediators of
treatment response for children with ADHD: The MTA Study.
Archives of General Psychiatry, 56, 1088–1096.
National Institute for Health and Care Excellence. (2019).
Attention deficit hyperactivity disorder: Diagnosis and man-
agement. Available from: https://www.nice.org.uk/guida
nce/ng87 [last accessed 11 January 2021].
National Institutes of Health. (1994). NIH guidelines on the
inclusion of women and minorities as subjects in clinical
research. Federal Register, 59, 14508–14513.
Nguyen, P.T., & Hinshaw, S.P. (2020). Understanding the
stigma associated with ADHD: Hope for the future? ADHD
Report, 28, 1–10.
Nigg, J.T., Sibley, M.H., Thapar, A., & Karalunas, S.L. (2020).
Development of ADHD: Etiology, heterogeneity, and early life
course. Annual Review of Developmental Psychology, 2, 559–
583.
Nussbaum, N.L. (2012). ADHD and female specific concerns: A
review of the literature and clinical implications. Journal of
Attention Disorders, 16, 87–100.
O’Grady, S.M., & Hinshaw, S.P. (2021). Long-term outcomes of
females with attention-deficit hyperactivity disorder:
Increased risk for self-harm. British Journal of Psychiatry,
218, 4–6.
Owens, E.B., & Hinshaw, S.P. (2016). Pathways from neu-
rocognitive vulnerability to co-occurring internalizing and
externalizing problems among women with and without
attention-deficit/hyperactivity disorder followed prospec-
tively for 16 years. Development and Psychopathology, 28
(4pt1), 1013–1031.
Owens, E.B., & Hinshaw, S.P. (2020). Adolescent mediators of
unplanned pregnancy among young women with and with-
out childhood ADHD. Journal of Clinical Child and Adoles-
cent Psychology, 49, 229–238.
Owens, E.B., Hinshaw, S.P., Lee, S.S., & Lahey, B.B. (2009).
Few girls with childhood attention-deficit/hyperactivity dis-
order show positive adjustment during adolescence. Journal
of Clinical Child & Adolescent Psychology, 38, 132–143.
Owens, E.B., Zalecki, C., & Hinshaw, S.P. (2017). Longitudinal
investigation of girls with ADHD. In L.T. Hechtman (Ed.),
Attention deficit hyperactivity disorder: Adult outcome and its
predictors (pp. 179–229). New York: Oxford University Press.
Pescosolido, B.A., Jensen, P.S., Martin, J.K., Perry, B.L.,
Olafsdottir, S., & Fettes, D. (2008). Public knowledge and
assessment of child mental health problems: Findings from
the National Stigma Study-Children. Journal of the American
Academy of Child and Adolescent Psychiatry, 47, 339–349.
Pfiffner, L.J., Hinshaw, S.P., Owens, E.B., Zalecki, C., Kaiser,
N., Villodas, M., & McBurnett, K. (2014). A two-site ran-
domized clinical trial of integrated psychosocial treatment
for ADHD-inattentive type. Journal of Consulting and Clinical
Psychology, 82, 1115–1127.
Pliszka, S., & AACAP Work Group on Quality Issues. (2007).
Practice parameter for the assessment and treatment of
children and adolescents with attention-deficit/
hyperactivity disorder. Journal of the American Academy of
Child and Adolescent Psychiatry, 46, 894–921.
© 2021 Association for Child and Adolescent Mental Health.

Polanczyk, G., De Lima, M.S., Horta, B.L., Biederman, J., &
Rohde, L.A. (2007). The worldwide prevalence of ADHD: A
systematic review and metaregression analysis. American
Journal of Psychiatry, 164, 942–948.
Polanczyk, G.V., Willcutt, E.G., Salum, G.A., Kieling, C., & Rohde,
L.A. (2014). ADHD prevalence estimates across three decades:
An updated systematic review and meta-regression analysis.
International Journal of Epidemiology, 43, 434–442.
Quinn, P.O., & Madhoo, M. (2014). A review of attention-
deficit/hyperactivity disorder in women and girls: Uncover-
ing this hidden diagnosis. The Primary Care Companion for
CNS Disorders, 16, PCC.13r01596.
Reid, R., Riccio, C.A., Kessler, R.H., Dupaul, G.J., Power, T.J.,
Anastopoulos, A.D., . . . & Noll, M.-B. (2000). Gender and
ethnic differences in ADHD as assessed by behavior ratings.
Journal of Emotional and Behavioral Disorders, 8, 38–48.
Rich-Edwards, J.W., Kaiser, U.B., Chen, G.L., Manson, J.E., &
Goldstein, J.M. (2018). Sex and gender differences research
design for basic, clinical, and population studies: essentials
for investigators. Endocrine Reviews, 39, 424–439.
Rokeach, A., & Wiener, J. (2018). The romantic relationships of
adolescents with ADHD. Journal of Attention Disorders, 22,
35–45.
Rucklidge, J.J., & Tannock, R. (2001). Psychiatric, psychoso-
cial, and cognitive functioning of female adolescents with
ADHD. Journal of the American Academy of Child and
Adolescent Psychiatry, 40, 530–540.
Rutter, M., Caspi, A., & Moffitt, T.E. (2003). Using sex
differences in psychopathology to study causal mechanisms:
Unifying issues and research strategies. Journal of Child
Psychology and Psychiatry, 44, 1092–1115.
Sarver, D.E., McCart, M.R., Sheidow, A.J., & Letourneau, E.J.
(2014). ADHD and risky sexual behavior in adolescents:
Conduct problems and substance use as mediators of risk.
Journal of Child Psychology and Psychiatry, 55, 1345–1353.
Seidman, L.J., Biederman, J., Valera, E.M., Monuteaux, M.C.,
Doyle, A.E., & Faraone, S.V. (2006). Neuropsychological
functioning in girls with attention-deficit/hyperactivity dis-
order with and without learning disabilities. Neuropsychol-
ogy, 20, 166–177.
Sellers, R., Harold, G.T., Smith, A.F., Neiderheiser, J.M., Reiss,
D., Shaw, D., . . . & Leve, L.D. (2021). Disentangling nature
from nurture in examining the interplay between parent-
child relationships, ADHD, and early academic attainment.
Psychological Medicine, 51, 645–652.
Shaw, P., & Sudre, G. (2021). Adolescent Attention-Deficit/
Hyperactivity Disorder; Understanding teenage symptom
trajectories. Biological Psychiatry, 89, 152–161.
Sibley, M.H., Arnold, L.E., Swanson, J.M., Hechtman, L.T.,
Kennedy, T.M., Owens, E., . . . & Rohde, L.A. (2021). Variable
patterns of remission from ADHD in the Multimodal Treat-
ment Study of ADHD. Manuscript submitted for publication.
Skoglund, C., Kopp Kallner, H., Skalkidou, A., Wikstr€ om, A.K.,
Lundin, C., Hesselman, S., . . . & Sundstr€ om Poromaa, I.
(2019). Association of attention-deficit/hyperactivity disor-
der with teenage birth among women and girls in Sweden.
JAMA Network Open, 2, e1912463.
Sonuga-Barke, E.J., & Halperin, J.M. (2010). Developmental
phenotypes and causal pathways in attention deficit/
© 2021 Association for Child and Adolescent Mental Health.
ADHD in girls and women 13
hyperactivity disorder: Potential targets for early interven-
tion? Journal of Child Psychology and Psychiatry, 51, 368–
389.
Staller, J., & Faraone, S.V. (2006). Attention-deficit hyperac-
tivity disorder in girls: Epidemiology and management. CNS
Drugs, 20, 107–123.
Swanson, E.N., Owens, E.B., & Hinshaw, S.P. (2014). Path-
ways to self-harmful behaviors in young women with and
without ADHD: A longitudinal examination of mediating
factors. Journal of Child Psychology and Psychiatry, 55,
505–515.
Tannenbaum, C., Greaves, L., & Graham, I.D. (2016). Why sex
and gender matter in implementation research. BMC Med-
ical Research Methodology, 16, 145.
Taylor, M.J., Lichtenstein, P., Larsson, H., Anckarsater, H.,
Greven, C.U., & Ronald, A. (2016). Is there a female
protective effect against attention-deficit/hyperactivity dis-
order? Evidence from two representative twin samples.
Journal of the American Academy of Child and Adolescent
Psychiatry, 55, 504–512.
Thapar, A. (2018). Discoveries on the genetics of ADHD in the
21st century: New findings and their implications. American
Journal of Psychiatry, 175, 943–950.
Timimi, S., & Taylor, E. (2004). ADHD is best understood as a
cultural construct. British Journal of Psychiatry, 184, 8–9.
Tung, I., Li, J.J., Meza, J.I., Jezior, K.L., Kianmahd, J.S.V.,
Hentschel, P.G., . . . & Lee, S.S. (2016). Patterns of comor-
bidity among girls with ADHD: A meta-analysis. Pediatrics,
138, e20160430.
Uchida, M., Spencer, T.J., Faraone, S.V., & Biederman, J.
(2018). Adult outcome of ADHD: An overview of results from
the MGH longitudinal family studies of pediatrically and
psychiatrically referred youth with and without ADHD of
both sexes. Journal of Attention Disorders, 22, 523–534.
Vildalen, V.U., Brevik, E.J., Haavik, J., & Lundervold, A.J.
(2019). Females with ADHD report more severe symptoms
than males on the adult ADHD self-report scale. Journal of
Attention Disorders, 23, 959–967.
Williamson, D., & Johnston, C. (2015). Gender differences in
adults with attention-deficit/ hyperactivity disorder: A nar-
rative review. Clinical Psychology Review, 40, 15–27.
Wolraich, M.L., Hagan, J.F., Allan, C., Chan, E., Davison, D.,
Earls, M., . . . & Zurhellen, W. (2019). Clinical practice
guideline for the diagnosis, evaluation, and treatment of
Attention-Deficit/Hyperactivity Disorder in children and
adolescents. Pediatrics, 144, e20192528.

Young, S., Adamo, N., Asgeirsd ottir, B.B., Branney, P., Beck-
ett, M., Colley, W., . . . & Woodhouse, E. (2020). Females with
ADHD: An expert consensus statement taking a lifespan
approach providing guidance for the identification and
treatment of attention-deficit/ hyperactivity disorder in girls
and women. BMC Psychiatry, 20, 404.
Young, S., Heptinstall, E., Sonuga-Barke, E.J., Chadwick, O.,
& Taylor, E. (2005). The adolescent outcome of hyperactive
girls: Self-report of psychosocial status. Journal of Child
Psychology and Psychiatry, 46, 255–262.
Accepted for publication: 5 May 2021